As a medical director of a large acute hospital trust, how people die in our care occupies quite a lot of my waking thoughts (and quite a few of my sleeping ones too…). I thought I knew quite a lot about this subject – coming into the role from a background of critical care (where death is common). I have found though that my experience, whilst a useful primer in the topic, has demanded significant additional learning on my part – this post is my attempt to share some of that learning.

People Die in Hospital – That’s what they do

There is a curious symmetry in the social changes that have occurred at both the beginning and the end of life. The realisation over the last half century or so that many of what were believed to be inevitable tragedies at the beginning and end of life were in fact amenable to technological intervention and thus avoidable – and the change in the medical profession from overseer and commentator of natural tragedy to intervener and preventer of such – has driven these life events from a home based setting managed by community based services into a hospital setting managed by doctors, nurses and midwives.

This is largely a good thing – more mothers and babies survive the traumatic vagaries of child birth than ever before and people live longer healthier lives than ever before.

There is one rather stark asymmetry though – whilst death and tragedy in child birth is now a very rare event indeed – death at the end of life is still ultimately inevitable. As a society, even though we know we have to die eventually, we still haven’t worked out how we should die. This means that the majority of people end up dying in hospital (over 50% of people – thanks to Shaun Lintern and Craig Stenhouse for correcting this for me!) with doctors and nurses trying to stop them from doing so even when death is inevitable.

This is not a good thing because dying with someone trying to stop you with all the technological weapons of modern medicine (however well meaning) is not a good way to die.

The alternatives – provided by the heroes of the hospice movement – remains a cinderella service, patchily provided, reliant on charity and sparsley funded by public money.

Avoiding the Unexpected

So, people die in hospital – in our two hospitals that is about 1600 people a year (about 1 in every 75 admissions or put another way 4 or 5 admissions every day don’t make it home alive).

When these deaths are studied they can broadly be categorised into three groups according to whether they are expected or unexpected deaths and avoidable or unavoidable deaths.

Category 1 – Unavoidable expected deaths. This is overwhelmingly the largest category of deaths in hospital. People reaching the end of their natural lives, where their frail bodily systems have reached a point where they provide no defence against otherwise modest insults such as a fall, a urinary tract infection or the flu. Dying in hospital, as I alluded to above, has become the natural order of things in modern Britain (and many other developed health care systems in the world). Also included in this category are the deaths that we would recognise as ‘palliative care’ where even 21st century medicine genuinely has no response – terminal cancer or devastating neurological disease.

Category 2 – Unavoidable unexpected deaths. These are the genuine tragedies that punctuate life in a hospital. The relatively rare, but affecting cases that litter the landscape of a professional career. These are the maternal deaths from catastrophic amniotic fluid embolus, the brain haemorrhage from an unsuspected cerebral vascular anomaly, the tragically successful suicide or the disastrous major trauma from a road traffic accident (sadly I could go on). These deaths are often met with heroic efforts on the part of hospital staff to prevent them and are followed by dismay and soul searching when unsuccessful. When deconstructed at a later date there is often some learning (we can always do better) but just as often there is little to be learnt – bad things just happen.

Category 3 – Avoidable unexpected deaths. These are the ones where we got it wrong. Where lapses, incompetence, inexperience, neglect and system failure succeed in lining up in a single case to either actually cause death or prevent avoidable death. These are the cases that stay with you (believe me). This is the missed diagnosis because of a failure to follow up a test result, the failure to act on the deteriorating patient, the unacceptable delay in life saving intervention or the failure to take responsibility for a situation. They are thankfully rare (and overwhelmingly the smallest category of death) – not because the lapses and system failures are rare – they are not – but because (other than in exceptional circumstances) it takes several in a row to have such a devastating outcome, the good old Swiss cheese effect.

I suppose in theory there is a fourth category of avoidable expected death – that feels like a contradiction to me and I can’t conceive what it might be.

The ‘management’ task here is to attempt to assign every death to one of the three categories. That is not a trivial task – and it is not one for which you can take a statistical short cut, however compelling a notion that might be. Not least because in every category there will be deaths where on review there is identified a lapse of care – yet how many lapses does it take to move a death from either of the first two categories to the third?

Lies, Damn Lies and Mortality Statistics

Regular readers of my blog will know that I have been here before in my earlier post: Thinking about Mortality – Fast and Slow. I am not going to rehearse the arguments of the weaknesses of case mix adjusted, risk modified mortality statistics. Suffice to say that the reported ‘dramatic improvement’ in HSMR of the 11 Keogh Review hospitals will have had as much to do with scrutiny of their coding practices as the quality of care they provide.

Professor Nick Black through the PRISM (and soon to be published PRISM 2) study has shown little correlation between quality of care and HSMR (or SHMI or RAMI or any other way of measuring institutional mortality rates). I am trying not to be cynical about these – because they are in fact very useful tools, and cannot be ignored. However one has to be very careful in interpreting them because they tell you as much about what type of hospital you are and what type of patients you treat as they do about the quality of care you provide.

I can tell you without looking that:

Small provincial district general hospitals with proportionately large elderly care, stroke and fractured neck of femur services will have high mortality ratios (however well risk adjusted).

Large urban inner city general hospitals with relatively young transient populations will have low mortality ratios.

Tertiary Centres that carry out high risk care on relatively young patients (like liver transplants or major cancer surgery) will have high mortality ratios.

A Recipe for Managing Mortality

So where does this leave us? We can’t trust the stats and identifying the deaths where we got it wrong, sufficiently to have at least been a causative factor in the death, requires painstaking review of very large numbers of deaths and the judgement of Solomon.

Here are my tips:

1) Don’t ignore the stats – have a committee that looks at your death rates in all specialties and diagnostic groups – identifies the variances, the outliers and the alerts and investigates them even if CQC or Dr Foster don’t notice. You will learn a huge amount about how care is delivered in your hospital and how patients are moved about within it. You will also learn quite a lot about coding.

2) Have a system in place that reviews every death in the hospital. Some have chosen the Medical Examiner solution to this – paying a recently retired doctor to review the notes of every death and extract learning and identify those where more scrutiny is required. We have gone down a variant of the trigger tool methodology – every case is assessed against a set of criteria by a consultant not involved in the care of that patient, if enough triggers are present in one case it gets a table top review.

3) Have a method of sharing the learning – particularly with the consultants doing the screening (in our case that’s all of them), it is laborious work and it has to feel worthwhile. We are not so good at this yet – we have a news letter that goes out, we could and should do more.

4) Don’t trust Dr Foster – they are a commercial organisation that profits from scare stories. Don’t ignore them either.

5) You will find that 70% of patients that fall into category 3 are due to sepsis – invest in physiological track and trigger, sepsis screening tools and implement the sepsis 6 bundle and critical care outreach. Your avoidable mortality will fall.

6) You will also find that acute hospitals provide dreadful care to the majority of patients for whom death is unavoidable and expected (Category 1). The fortunate minority that find themselves under the care of palliative care doctors will get excellent care, the majority that don’t, won’t. Invest in end of life services – this has to be the greatest single priority for the NHS. We are about to publish our ‘Last Year of Life Audit’ – an investigation into the care provided in that critical period of a persons life. It will show that we admit to hospital on average three times in the last six months and start ‘supportive care’ on average 24 hours prior to death.

7) Finally – keep the politicians out, they don’t get it and never will and will do a great deal of harm meddling with stuff they don’t understand. You wouldn’t let them meddle with airport safety would you? why would you let them meddle with hospital mortality…?

Over the next 2 years many NHS Hospitals will be replacing electronic health record (EHR) systems as the contracts born out of the national program for IT (NPfIT) come to an end. They are doing so amid a noisy revolution in healthcare informatics – which is demanding that we completely reframe not just our ideas about the EPR itself but also the nature of healthcare delivery and the traditional medical model.

I have previously talked about the cumbersome desk bound IT systems that have been as much an impediment to the process of care as a source of misery for the users of these systems. Why is there such a mismatch in expectations of healthcare staff and the developers of the tools supposedly there to help them? I don’t believe we can blame the developers of the systems – or for that matter the users of them. I believe that it has come about because we have all failed to understand the true nature of modern medicine and it has taken the social media revolution to wake us up to the fact.

Transactional Healthcare

All our current systems – IT, contracting, measuring, counting and operational delivery – are designed around the notion that healthcare is a series of individual transactions, each transaction taking place under the auspices of an individual clinician (e.g. the finished consultant episode – FCE). The overriding assumption of this model is that healthcare is episodic, that between episodes we have no contact and no need for contact with the healthcare system and that each episode is presided over by a clinician that has, if not control, then at least knowledge of what is happening. It also assumes that of the information required to manage an episode of care only a proportion of it is of relevance to future episodes – and that episodes of care have largely self contained information needs.

Notwithstanding this, what a typical patient might consider a single episode of healthcare actually consists of large numbers of individual transactions often with several different organisations and several different parts of the same organisation (GP, Outpatient department, Radiology, Pathology etc.). The ‘system’ has fragmented itself – for its own purposes – and has at the same time failed to provide a reliable mechanism for the sufficient sharing of information between its different parts to give any sense of continuity – let alone impression of competence – to the hapless patient.

The NHS far from being a single organisation is an aggregation of large and small institutions, thrown together in a pseudo-market notionally in competition with each other – with strict rules that prevent them from collaborating (competition law) and sharing information (data protection). It is designed to fail to meet the continuity challenge and the expectations of patients. It is also unsafe – with manifold opportunities for vital information communication failure, a common root cause of critical incidents and serious complaints.

This transactional model has developed out of the medical model that assumes patients have singular diagnosable diseases that are amenable to technological intervention (pharmaceutical or surgical) and that life long cure is the outcome. This is certainly the case in a proportion of healthcare interactions – but medicine and patients are changing. The vast majority (in excess of 70%) of healthcare delivery is for the multiply co-morbid patient with conditions that they will live with for the rest of their lives. There may indeed be episodic deteriorations in their condition, that result in (expensive) episodes of highly technological healthcare – these are however often both predictable and avoidable manifestations of a long term condition for which there is a continuous healthcare need.

Social Healthcare

A new medical model – that fits the needs of 21st century patients – is emerging in the era of social networking. Social Healthcare – this model assumes that the patient has a continuous need for health intervention and that this is delivered by a network of providers that the patient invites in to their ‘health space’. A long term condition demands a multitude of interactions over a sustained period of time with many providers. Our current system fails to ensure that those providers interact with each other over the same patient using the same information as it cannot guarantee that they ever have access to the same information (or even know that they are looking after the same patient). In the social healthcare model the patient is the guardian of all information about themselves. Their information sits in ‘the cloud’ but they hold the key to its access. Over time they build a personalised health care team who have access to their cloud data and can ‘talk’ to each other about the patient through his or her ‘health space’. The patient can source information about their condition, ask advice or consult through the portal to their health space at any time of day or night. The portal allows for direct consultation through a skype like interface. Even more powerfully the patient can consult with other patients who have the same conditions. A self supporting community emerges that can provide advice, support and shared experience – on a continuous basis. “It’s like having a waiting room conversation with 1000 other people – just like me”.

This new model has the potential to have a powerful enabling impact on patients. It subverts the traditional hierarchy in the health transaction, puts all providers on an equal footing below that of the patient – who becomes the master of their own information. Networks of expert patients start to generate new kinds of knowledge about the nature of disease and the impact of interventions – crowd sourced evidence creating medicine. Patients have the power to choose who contributes to their health space – based on the value they add to them as individuals.

Preparing to be part of the Crowd contributing to the Cloud

What does this mean for providers of health care that are in the process of renewing their informatics systems? What does this mean for me as an individual doctor? The truth is the system described above doesn’t yet exist – there is nothing yet that will force me as a doctor to change my clinical practice in such a way as to make myself available through the cloud to individual or groups of patients on a continuous basis. There is nothing yet that will force the hospital that I work for to make available all the information it holds about patients to patients through a cloud portal – or share that information with other providers of that patient’s choosing. Nothing yet – but it is coming…

Third party providers of patient centred health portals are are emerging – from a variety of premises and care models – but are converging on something that looks similar to the ‘social healthcare’ system. Patients like me, Patients Know Best, Health Fabric and Skype Health are all examples of emerging technologies that will deliver the vision. And they are selling their wares not to doctors, healthcare institutions or commissioners – they are selling them to patients.

What this means then is that the systems we purchase or develop will need to have the ability to talk to these providers, transfer information, support voice and video links. We will have to think through how the information outcomes of healthcare transactions will be recorded in a way that can meaningfully sit in a patient’s cloud – shareable with other providers and understandable by patients.

What this means for doctors is a shift from practicing intermittent transactional healthcare – to developing a personal online continuous relationship with our patients and being part of and interacting with the crowd of providers that are also caring for them.

As a medical director I am routinely required to assess, grade and act on the results of serious adverse events that have occurred in hospital. Often these events have resulted from failures of care through lapses, oversights, errors or neglect. This is often accompanied by a clarion call for some form of disciplinary action and or restitution – usually most insistently from within the organisation rather than by those directly affected, either carers or the patients themselves.

Bad things happen in hospital all the time. Healthcare is the only industry where for a significant minority of users the outcome is death or injury, either expected or unexpected. The overwhelming priority in this situation for both the recipients and providers of the care is learning: learning the truth of events, learning if it was avoidable, learning how it might be avoided in the future, and sharing that learning so it might be avoided elsewhere.

Prerequisites for Organisational Learning

We have, as human beings, an innate gift for learning – it is built into our DNA and, whilst most active in our early years of life, never really leaves us. Individual learning is the most powerful lever of change in human societies, because people love to learn and change as a result. Teams and organisations are made up of people and yet team and organisational learning does not happen by chance as it does for individuals – team learning is an unnatural and deliberate act.

There are three prerequisites needed within organisations in order to promote learning from error and system failure. It is strangely rare to find them all reliably present in healthcare organisations.

A Learning Environment

A Team Based Learning Infrastructure

A Compelling Vision Delivered Through Leadership

I will expand on these three prerequisites, but first I want to explore why they are found rarely in our hospitals and healthcare organisations.

Two Key Barriers to Organisational Learning in Hospitals

Hospitals are busy places, this is a universal truth – not unique to the NHS. The work processes of nurses and doctors in hospitals rarely run smoothly – they are by their nature characterised by frequent interruptions, unexpected deviations and minor crises. In order to get the job done a large part of the work involves having to create on-the-hoof workarounds and solutions to problems – giving rise to the familiar sense of almost continuous ‘fire fighting’.
We are actually incredibly successful at doing this, much of our individual innate learning capacity is consumed developing coping strategies for the chaotic environment we find ourselves in. The problem with this ‘first order problem solving’ for ‘low level failure’ is that the learning it generates is of value only to the individual nurse or doctor – they are simply adapting to the flawed environment they find themselves in – just to get the job done. In doing so they are condemning themselves and and their successors to having to learn the same lessons in perpetuity – this grinds you down and drives talent away from ‘the front line’. How do we break the cycle of low level failure that requires constant first order problem solving making every day work flow inefficient and time consuming? The first step is to recognise the problem and then acknowledge that low level failure, whilst common place, is neither inevitable nor acceptable. The next step is to then deliberately and collectively make the time to move first order problem solving into second order problem solving (of which more later).

The second key barrier to organisational learning in hospitals is a deeper, more cultural one. This is to do with interpersonal attitudes and responses to error. The shameful truth is that the overwhelmingly pervasive culture is a blaming one that inhibits speaking up with questions, concerns and challenges that might otherwise have caught and corrected human error. Moreover there is a culture in medicine that does not encourage admissions of error. Both ourselves and others have high expectations of success in medicine – when we don’t meet those expectations we are as blaming of ourselves as we might expect others to be. What is interesting is that the direction of blame isn’t just top down – in fact top down blame only really materialises when the failures mount up to catastrophic levels. The vast majority of, and undoubtedly more corrosive, blame is that of our colleagues and peers. What is clear is that whilst blame remains the primary response to failure opportunities for learning will be lost and the quality of the lessons learnt will be poor. Overcoming this barrier is a true challenge of leadership at all levels of an organisation as it requires a change in culture – a clear and sustained statement and restatement of values, unwavering adherence to behaviours that follow from those values, even in the face of challenges from within and without the organisation.

Leading Learning for Patient Safety

So where should we start with creating a learning culture in our organisations? The answer has to be with leadership, because without leadership on this issue nothing else can follow. The type of leadership and skills required to lead learning, however, are not what are typically viewed as traditional leadership skills. The leadership model for leading learning differs from the traditional leadership model in several important ways:

Whilst a ‘burning platform’ undoubtedly exists, the future state can only be guessed at (in an educated way)

This makes it hard to articulate

The flaws in the current state are hard to spot – there is a deep seated culture of acceptance of low level failure

The way forward is not a clear plan with deadlines and critical paths but a process of experimentation, a gradual reduction of uncertainty and regular revision of interim goals and ultimate vision

The leadership task is primarily one of engagement and reduction of fear not a promotion of employee effort

The task will never be finished

If you have read my previous blogs you might guess that I believe these ‘New Model Leaders’ need to come from the rank and file of doctors, nurses and other healthcare professionals that don’t often put themselves forward for such a role.

Second Order Problem Solving and A Team Based Learning Infrastructure

Second order problem solving is about creating long term fixes for recurrent problems, it is about analysing root causes and putting in place solutions with ‘traction’, it is often about changing behaviours in ourselves that have consequences for others. There are several reasons why we don’t stop and take the time and effort required to convert first order to second order problem solving. First of all – it does take both time and effort – neither of which we have much left of after a day / week / month / years of fire fighting. Secondly the problems we need to solve are quite often not even perceived as problems, we have been compensating for so long it has just become part of the job – this is where our new model leader has to be insightful. Thirdly second order problem solving requires some quite specific skills such as root cause analysis, process mapping, and change modelling that are not commonly found in healthcare teams. Fourthly – we are quite proud of our first order problem solving, being a coper and thriver in a stressful front line job is associated with significant kudos, particularly in the hospital environment. Finally it does require us to meet as teams for a significant time on a regular basis – which we are astonishingly bad at doing – and when we do for those team meetings to be led in a way that promotes speaking up, learning from others, admissions of failure and a willingness to innovate (and therefore risk failure). This final requirement leads on to the the final pre-requisite for organisational learning – an environment of psychological safety – A Learning Environment

Our new model leaders have their work cut out – not only do they have to create time (in an already overloaded time table) to bring together teams (who are singularly reluctant to gather) to discuss both low level and high level failure (failures that may not even be recognised as such) and defend these notions against pressures to use the time ‘more productively’; but also resist the temptation and pressures from above, inside and out to apportion blame for every failure that comes to light. The prize is great if they achieve it – a learning environment in an organisation that continually improves both itself and the people that move through it, one that delivers both on the economic and quality front. A true value adding organisation.

But – it can’t all be so idyllic surely? People do also make mistakes borne out of stupidity, brazen over confidence, ignorance, stubbornness, laziness, jealousy and – yes – even malice. There is a level of human behaviour for which we all need to be held account. There is also a performance imperative, we all have to be helped to raise our game. Where is the place for accountability in a blame free culture? The diagram below will perhaps help you decide…

This is the essential difference between ‘blame free’ and ‘psychologically safe’ for the latter comes not just from creating an environment where people feel able to speak up and admit failure but also feel assured that when boundaries are truly crossed that individuals will be held to account. This is the real test of leadership – knowing and communicating expectations and boundaries as well.

Blameworthy Acts – the Boundaries of a Blame Free Culture

Where do you draw the boundaries? There are no text books, there are no rules – there is intuition and there are inspirational leaders we can follow. Here is my starter for ten of blameworthy acts:

Reckless behaviour

Disruptive behaviour

Working significantly outside your capability

Disrespectful behaviour

Knowingly violating standards

Failure to learn over time

Failure to work as a team

Covering up

No doubt there are more. Clear boundaries around a learning zone create an environment in which organisations can thrive and patients can feel and be safe.

I have to acknowledge the source of the ideas for this article. Amy C Edmonson – a truly inspirational teacher at HBS who not only articulates this message with conviction but backs it up with the irrefutable results of research both in healthcare and other settings.

It is interesting to reflect – now that the PFI bonanza has come to an end and we all have to hunker down and work out how to pay for it for the next 30 years – on what we have spent all the money on and consider whether what we have thrown up around the land is actually what we need.

This paper by the think tank Reform The Hospital is Dead Long Live The Hospital is an eloquent exposition of Clayton Christensen’s ‘Innovator’s Prescription’ within an NHS context. The essential conclusion of both of these is that Hospitals need to move from being ‘A place where sick people go’ to becoming ‘An organisation that keeps people well’. This re-framing of purpose prompts the question – what does a hospital that keeps people well look like? I suspect it is not a large building with lots of beds in it (or clinic rooms for that matter).

Interestingly the specialty of Intensive Care Medicine underwent a similar re-framing of purpose over ten years ago as a result of the comprehensive critical care program in response to a lack of intensive care beds. The outcome of this process was the introduction of critical care outreach teams (or medical emergency response teams) linked to a system of population surveillance (MEWS track and trigger) and an expansion of lower acuity beds (high dependency). There were almost no additional intensive care beds commissioned or provided. The result has been intensive care units have been able absorb ten years of demand growth, almost eliminate the need for inter hospital transfer for capacity reasons, reduce futile care, contain costs and improve outcome.

How do we replicate this operating model at the scale of the hospital within a health economy (as opposed to an intensive care unit in a hospital)? The essential elements are:
1) Knowing the population you are caring for – a disease registry
2) Knowing how they are – a simple method of measuring disease status
3) A response team that averts crisis when a trigger threshold is reached – a specialist community team
4) An escalation pathway that includes rapid access to specialist input – specialty hubs
5) Lower acuity beds for step up or step down care – intermediate care beds
6) Alternate pathways for those that acute care is inappropriate – end of life services
7) Acute beds for those that genuinely need it – closely linked to an intensive care unit!

This distributed model of care does still need buildings – but what it needs more is intelligent information and communication systems used by a workforce that understands the need to keep patients other than those in genuine need away from hospital. It also needs an operating system that measures its impact, analyses unexpected pathway deviance and learns from system failure.

Eliminating the huge waste in the system of inappropriate and futile hospital care (both inpatient and outpatient) will not only deliver cost savings it will improve quality of care and outcomes and create the capacity we need for the growth in demand we know is coming.

The hospital is no longer a building it is a healthcare delivery system. We should be investing in the infrastructure that makes it possible – And that is not bricks and mortar…